Initial Comments:
A focused fundamental survey was conducted November 28-30, 2023, to determine compliance with the requirements of the 42 CFR Part 483, Subpart I Regulations for Intermediate Care Facilities. The census during the survey was four and the sample consisted of two individuals. One deficiency was identified.
Plan of Correction:
483.460(k)(2) STANDARD
DRUG ADMINISTRATION
Name - Component - 00
The system for drug administration must assure that all drugs, including those that are self-administered, are administered without error.
Observations:
Based on observation, record review and staff interview, it was determined that the facility failed to administer nutritional supplements without error. This was noted for the only individual in the sample who was prescribed nutritional supplements (Individual #1). The findings included:
A) Observations of the medication administration and breakfast meal were conducted on November 28, 2023, from 6:35 AM to 8:00 AM. These observations revealed that Individual #1 was given crushed oral medications in pudding and ate a pureed meal.
B) A reconciliation of the medication administration and physician's orders was performed the same day. Review of physcian's orders for this individual, dated November 14, 2023, revealed that two nutritional supplements were prescribed. Boost Breeze, oral liquid, drink one bottle three times a day with meals; and ProSource Gelatein Plus, one container twice a day with meals. These nutritional supplements were not offered during the breakfast meal. Review of the current medication administration record revealed that these supplements were documented on the record; but were not signed as being administered.
C) The program director (PD) was interviewed on November 28, 2023, at 9:30 AM. The PD stated that the prescribed supplements were not obtained for Individual #1. The PD acknowledged that this individual did not receive the prescribed nutrional supplements from November 14, 2023 to date.
Plan of Correction:TThe deficient practice observed on November 28, 2023 was investigated to determine whether neglect occurred. Targets were immediately identified and removed from administering medication until retaining could be completed. The Program Director verbally retrained all Direct Support Professional (DSP) staff, who were identified as targets, on November 28, 2023, and followed up with documented retraining. Retraining was completed in regards to assuring the system for drug administration assures that all drugs, including those that are self-administered, are administered without error. Training included, but was not limited to:
o The importance of reviewing all pages of the MAR to assure all medications, supplements, and treatments are administered as ordered.
o The importance of identifying that if a medication, supplement, or treatment is not available for administration, this needs to be identified as a medication error, in need of immediate reporting.
o The importance of completing Overnight Medication Checklist carefully. These checks ask if all oral medications are present, and if all meds are present, including PRN for individuals.
o Policy 304-5 Incident Reporting/Investigating – Department of Health related to medication errors.
o Policy 304-5 Incident Reporting/Investigating – Department of Health related to neglect.
o Policy 208-7d Medications with Attachments: related to receiving/distribution.
The Executive Director reviewed the deficient practice with the target identified in the business office and verbally retrained, prior to December 13, 2023. A written training was developed by the Program Director, and forwarded to the Executive Director on December 14, 2023, to be reviewed with this target. Training includes the above bullets as well as the business office's role on the ordering and procurement process. This includes the importance of timely Interdisciplinary Team communication, the established email distribution group for accurate communication, and the electronic path to follow to find the directory of phone numbers when no response is received to emails.
All training records were forwarded to the Certified Investigator and to People Operations and added to the employee's training file. The Administrative Review Team will assure all targets are trained by comparing the training records to the target list, and signing and dating the investigation file.
Individual #1's Boost Breeze and ProSource Gelatin Plus was delivered on November 30, 2023.
The Director of Nursing will address the process for ordering supplements through the business office when making revisions to policy 208-7d, Medications with Attachments. This will include a system of checks and balances to assure the business office receives the request for the order from the program, responds that the order has been placed, and follows up to assure the order has been received. The Health Services Coordinator will be responsible for submitting new orders to the business office, and the QIDP, or designee, will be responsible for tracking the inventory on site, and requesting refills as needed. The business office will be required to respond to requests for new orders, and refills within 72 hours, to account for weekends, and follow up to assure products have been received within 48 hours of the expected delivery date. The QIDP, or designee, will be responsible for confirming or denying receipt of orders within 24 hours. The target date of completion is February 1, 2024.
The Executive Director will follow up with the business office, and Program Coordinator with the QIDP, once the policy has been updated to provide training on the new procedure. Documentation of the training will be forwarded to People Operations and added to the employee's training file. The target date of completion is February 15, 2024.
The Program Director is in the process of revising the responsibilities of the Residential Program Leader position. The responsibility for completing the weekly Supervisor Medication Check when the supervisor position is vacant, and/or as delegated, will be included. Medication Checks are designed to assure the system for drug administration assures that all drugs, including those that are self-administered, are administered without error. The target date of completion is February 1, 2024.
All additional recommendations identified through the investigation process will be implemented.
Failure to follow the steps outlined in this plan of correction will lead to re-training and the policy for progressive discipline will take effect.
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